It can be appropriate to prescribe multiple medicines for someone with complex or multiple illnesses if there is evidence of the benefits, and harms are minimised. But we know taking multiple medicines strongly increases the risk of unwanted side effects such as drowsiness, dizziness, confusion, falls and injuries and even hospitalisations.
Older people may be taking medicines that are not working or no longer needed; medicines may have been prescribed to treat the side effects of other medicines (prescribing cascade); other treatment options may be more suitable; or they may have difficulty taking the medicines.
Reducing these inappropriate and unnecessary medicines in older people is one of the most important challenges of modern medicine.
For example, let’s consider Robert, a 60-year-old man who starts taking blood-pressure-lowering medicine to reduce his chance of having a heart attack or stroke. He tolerates this well for many years and continues taking the medicine, as his doctor told him he needs to take it for the rest of his life.
By the age of 80 he is on ten medicines for various conditions (including arthritis, reflux and sleeping problems) and starts to get dizzy spells. On occasions the dizziness has led to a fall, and his concerns about falling have made him less independent.
What can be done in Robert’s case? Reviews of studies where medicines are selectively and carefully stopped (also called “deprescribing”) show reducing specific types of medicines, such as blood-pressure-lowering medicine, can be done without causing harmful withdrawal effects. In the case of medicines such as antidepressants or sleeping tablets, reduction can even have the benefits of reducing the risk of falls and improving cognition.
However, discussions between doctor and patient about coming off medicines are not easy and there is little guidance on how to do it. We are used to talking about why medicines need to be started, but less familiar with stopping or reducing the doses of medicines.
The evidence for the benefit of many medicines is less clear for older patients as randomised controlled trials generally study younger populations with no other illnesses. This means, especially for older people, that the balance of potential benefits versus harms depends on what is important to the individual patient.
Robert’s priority might be living independently by avoiding dizziness and reducing his risk of having a fall. He therefore may prefer to reduce his blood-pressure medicine. His friend James may be more concerned about avoiding death or disability from a heart attack or stroke. He therefore may prefer to continue his medication and accept he may experience dizzy spells as a result.
Biases in the way we think often influence decisions on medicine. Patients may not realise change is an option, doctors may incorrectly assume patients always want to stay on their medicines, and older people may experience cognitive changes that make it more challenging for them to be involved in an informed decision. But all of these issues can be overcome with good communication.
Using Robert’s situation as an example, here are four steps to ensure an informed and shared decision about deprescribing.
1. You have options
Continuing, reducing the dose, or discontinuing blood-pressure medicine should all be identified as options to manage the problem of dizziness.
2. Discuss the harms and benefits
The likelihood of preventing a heart attack or stroke by continuing blood-pressure medicine versus preventing dizziness or falls by reducing or stopping the medicine should be discussed. This should take into account other medicines taken and the strength of the evidence for the relevant age group.
3. What does the patient want?
Robert’s concerns about reduced independence after a fall now, versus death or disability from a heart attack or stroke in the future, should be discussed. This includes talking about possible trade-offs between quality of life in the short term and life expectancy in the long term.
4. Make a decision
A decision about maintaining, reducing or stopping blood-pressure medicine should be made by Robert together with his doctor, carer and/or family, depending on who Robert wants to be involved. The decision made now can be changed later on.
If patients have any concerns about their medicines, experience troublesome symptoms or think a medicine may no longer be needed, they should talk to their GP or pharmacist about reviewing their medicines and discussing the potential for reducing or stopping. More information about medicines and older people is available on the NPS Medicinewise website.
Deprescribing, or carefully ceasing medicines, is not taking away care; it is a positive strategy that reduces avoidable harmful effects and can improve quality of life.